Utility of unidimensional and functional pain assessment tools in adult postoperative patients: a systematic review

A Systematic Review of Multimodal Analgesic Effectiveness on Acute Postoperative Pain After Adult Cardiac Surgery

AIM

To synthesise the best available empirical evidence about the effectiveness of multimodal analgesics on pain after adult cardiac surgery.

DESIGN

A systematic review with meta-analysis.

METHODS

Indexed full-text papers or abstracts, in any language, of randomised controlled trials of adult patients undergoing cardiac surgery investigating multimodal postoperative analgesic regimen effect on mean level of patient-reported pain intensity at rest.

DATA SOURCES

Eight databases, via two platforms and three trial registries were searched from 1 January 1995 to 1 June 2024 returning 3823 citations.

RESULTS

Of the 123 full-text papers assessed, 29 were eligible for inclusion. Data were independently extracted by a minimum of two reviewers in Covidence. There were 2195 participants, aged 60.4 ± 6.6 (range 40-79) years, who were primarily male (n = 1522, 76.1%), randomised in the included studies. Risk of bias was high and reporting quality was poor. Patient-reported pain was measured at rest in 28 (96.6%) trials. Data were suitable for pooled analysis from 10 (34.5%) of these trials with an average rest pain intensity of 3.3 (SD 1.5) in the control and 2.7 (SD 1.9) in the intervention groups, respectively. No trials compared combinations of nonopioid, opioid-agonist-antagonist, partial opioid agonists or full opioid agonists. Most trials (n = 11, 37.9%) compared two different full opioid options for less than 72 h (n = 24, 82.7%).

CONCLUSIONS

Robust trials are needed to determine which multimodal analgesic combination will optimise patient recovery after adult cardiac surgery. There is an urgent need to test and refine high-quality end-point measures.

IMPLICATIONS FOR PATIENT CARE

Adequate assessment precedes ideal pain treatment. The findings from this review reveal neither are sufficient, and the impact of suboptimal pain management on postoperative recovery is grossly underinvestigated.

IMPACT

The optimal combination of multimodal analgesics is unknown despite being recommended in best practice guidelines for enhanced recovery after cardiac surgery. Almost 30% of adults continue to experience ongoing pain up to a year after cardiac surgery, and findings from this review reveal a dearth of robust empirical evidence for optimal pain management, and heterogeneity in the way pain is assessed, measured and managed. This review provides a premise for robust trials focused on acute postoperative recovery in cardiac surgery and beyond.

REPORTING METHOD

This review was conducted in accordance with the PRISMA-P statement.

PATIENT OR PUBLIC CONTRIBUTION

There was no patient or public contribution.

PROTOCOL REGISTRATION

PROSPERO: CRD42022355834.

The psychometric assessment of the older adult in pain: A systematic review of assessment instruments

We conducted a systematic review of pain assessment tools suitable for community-dwelling older adults. For this work, we conceptualized existing psychometric tools as falling under the following domains: a) pain intensity/characteristics; b) pain-related interference/disability; c) coping strategies; d) pain beliefs/attitudes/cognitions; e) pain-related fear and anxiety; and f) pain-specific emotional distress. Multi-dimensional and condition-specific tools were also considered. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of patient-reported outcome measures guided the evaluation of measurement properties, quality of evidence ratings, and recommendations for each measure. A search of Medline, PsycINFO, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature, yielded a total of 21,755 records. Of these, 120 studies, focusing on 57 psychometric tools, were included in this review and categorized into the aforementioned pain assessment domains. The availability of psychometric studies with older adult populations was insufficient for most tools and the quality of evidence ranged from very low to high. Only a small number of tools met the criteria for a strong or tentative recommendation favoring their use. We identified gaps that should be addressed in future research.

Use of opioids and opioid alternatives during general anesthesia: a pan-Canadian survey among anesthesiologists

PURPOSE

While there is limited patient-centred evidence (i.e., evidence that is important for patients and end-users) to inform the use of pharmacologic opioid minimization strategies (i.e., the use of opioid alternatives) for adult surgical patients requiring general anesthesia, such strategies are increasingly being adopted into practice. Our objectives were to describe anesthesiologists' beliefs regarding intraoperative opioid minimizing strategies use and utility, and to explore important clinical decision-making factors.

METHODS

We conducted a pan-Canadian web-based survey of anesthesiologists that was distributed using a modified Dillman technique. Our multidisciplinary team, including a patient partners panel, participated in the process of domains and items generation, items reduction, formatting, and composition. Our sampling frames were members of the Canadian Anesthesiologists' Society and members of the Association des Anesthésiologistes du Québec. We used the newsletters of each organization to distribute our survey, which was available in English and French and housed on the LimeSurvey (LimeSurvey GmbH, Hamburg, Germany) platform.

RESULTS

From our eligible sampling frame, 18% completed the survey (356 respondents out of 2,008 eligible participants). Most of the respondents believed that using opioid minimization strategies during general anesthesia could improve postoperative clinical outcomes, including pain control (84% agree or strongly agree, n = 344/409). Reported use of pharmacologic opioid minimization strategies was variable; however, most respondents believed that nonsteroidal anti-inflammatory drugs, acetaminophen, N-methyl-D-aspartate receptor antagonists (ketamine), α2-adrenoceptor agonists (dexmedetomidine), corticosteroids, and intravenous lidocaine improve prostoperative clinical outcomes. The primary factors guiding decision-making regarding the use of opioid minimization strategies were postoperative acute pain intensity, the impact of acute pain on functioning, patient well-being (i.e., quality of recovery) and patient satisfaction with care. A lack of evidence was the most important barrier limiting the use of opioid minimization strategies.

CONCLUSION

In our survey of Canadian anesthesiologists, several opioid minimization strategies were believed to be effective complements to general anesthesia, although there was substantial variation in their reported use. Future randomized controlled trials and systematic reviews evaluating the effectiveness of opioid minimization strategies should prioritize patient-centred outcome measures assessment such as the quality of recovery or the impact of acute pain on functioning.

A critical approach to research on perioperative pain management

Optimal postoperative pain management is a prerequisite for enhancing functional recovery after surgery. However, many studies assessing analgesic interventions have limitations. Consequently, further improvements in study design are urgently needed. In this focused editorial, we critically review prevalent trial designs and outcome measures including treatment-related adverse events evaluating analgesic interventions. Novel clinical trial designs should improve efficiency and enhance the likelihood of detecting relevant treatment effects. Cohort and database studies using propensity score matching and directed acyclic graphs could provide real-world generalisable information. Procedure-specific and patient-specific trials should allow identification of subpopulations most likely to benefit from a particular intervention after a specific surgical procedure and thus ascertain optimal analgesic strategies in challenging populations.

Measurement of acute postoperative pain intensity in orthopedic trials: a qualitative concept elicitation study

BACKGROUND AND PURPOSE

Pain intensity is an important outcome in clinical trials of surgery because pain relief is important to patients. Currently, recommended scales are the numeric rating scale 0-10 and visual analogue scale. However, these scales allow for considerable influence of individual imagination, previous experience, and coping skills, limiting proficiency in comparative clinical trials. We aimed to explore postoperative expressions of "how much it hurts"-the first step to improve pain intensity measurement.

METHODS

This was a qualitative study using inductive content analysis: words and visual cues describing pain intensity were collected from (i) existing pain intensity measures by search of COSMIN, PubMed, and Google, (ii) patient interviews recorded and transcribed word-for-word, (iii) clinician interviews transcribed likewise, and (iv) 100 patient telephone interviews with notes taken. After familiarization, the collected expressions were labelled inductively in categories and assembled in tables (case and theme-based matrices).

RESULTS

Descriptors fell into 12 categories: intensity (slight/strong), evaluative (negligible/unbearable), cognitive impact (distracting/can be ignored), activity impact (limits some/all activity), sleep impact (can/cannot sleep), examples (like stubbing a toe), physical signs (crying/writhing), associated symptoms (nauseating/tiring), treatment (ice helps/need morphine), affective (annoying/dreadful), discriminative (aching/piercing), and general recovery (hindering recovery/functional interference). Many visual cues were also identified. Literature and recorded interviews gave rise to the categories, and telephone interviews found saturation, providing no further categories.

CONCLUSION

Pain intensity is expressed by terms that fall into 12 categories and by a variety of graphic elements. This advances development of a patient-reported outcome measure of pain intensity for orthopedic trials.

Peri-operative pain management in adults: a multidisciplinary consensus statement from the Association of Anaesthetists and the British Pain Society

BACKGROUND

Nearly half of adult patients undergoing surgery experience moderate or severe postoperative pain. Inadequate pain management hampers postoperative recovery and function and may be associated with adverse outcomes. This multidisciplinary consensus statement provides principles that might aid postoperative recovery, and which should be applied throughout the entire peri-operative pathway by healthcare professionals, institutions and patients.

METHODS

We conducted a directed literature review followed by a four-round modified Delphi process to formulate recommendations for organisations and individuals.

RESULTS

We make recommendations for the entire peri-operative period, covering pre-admission; admission; intra-operative; post-anaesthetic care unit; ward; intensive care unit; preparation for discharge; and post-discharge phases of care. We also provide generic principles of peri-operative pain management that clinicians should consider throughout the peri-operative pathway, including: assessing pain to facilitate function; use of multimodal analgesia, including regional anaesthesia; non-pharmacological strategies; safe use of opioids; and use of protocols and training for staff in caring for patients with postoperative pain.

CONCLUSIONS

We hope that with attention to these principles and their implementation, outcomes for adult patients having surgery might be improved.

To Be in Pain: Pain Multidimensional Questionnaire as Reliable Tool to Evaluate Multifaceted Aspects of Pain

Background/Objectives: Pain is a multidimensional experience influenced by sensory, emotional, and cognitive factors. Traditional pain assessments often fail to capture this complexity. This study aimed to develop and validate the Pain Multidimensional Questionnaire (Pa-M-QU), a new self-report tool designed to assess pain catastrophizing, sensitivity, and coping strategies. Methods: Two independent samples of Italian-speaking participants, aged 18 and above, were recruited online. The first sample (n = 392; mean age = 29.36) was used for exploratory factor analysis (EFA), and the second sample (n = 123; mean age = 28.0) for confirmatory factor analysis (CFA). Pearson's correlations and convergent validity analyses were conducted. Results: From an initial pool of 59 items identified through focus group discussions, 35 items were removed based on reliability analysis. The final 24-item Pa-M-QU features a three-factor structure: catastrophizing, pain sensitivity, and coping with pain. Conclusions: The Pa-M-QU offers a rapid, non-invasive assessment that captures the multidimensional nature of pain. It is a starting point to develop tools for both clinical and research settings, aiding in evaluating pain in healthy individuals and predicting acute and chronic pain disorders. Future research should focus on refining the Pa-M-QU for broader clinical applications and exploring its potential to complement or replace traditional pain assessments, thereby advancing pain management and research.

Effect of a comfort scale compared with a pain numerical rate scale on opioids consumption in postanaesthesia care unit: the COMFORT study

BACKGROUND

The way that pain is assessed in the PACU could impact on postoperative pain and analgesic consumption. However, there is currently no evidence to support this speculation. The authors hypothesised that using a comfort scale reduces postoperative opioid consumption when compared with a standard numerical rating scale (NRS) to evaluate pain in the PACU.

METHODS

In this cluster-randomised trial, patients were assessed using either a comfort scale (comfort group) or a pain NRS (NRS group). The primary outcome was the opioid consumption in the PACU. The main secondary outcomes were postoperative pain, nausea and vomiting, length of stay in the PACU, and satisfaction.

RESULTS

Of 885 randomised patients, 860 were included in the analysis. Opioid consumption in the PACU was comparable in the comfort and NRS groups (median [interquartile range [IQR] 0 (0-5) vs 0 (0-6); P=0.2436), irrespective of the type of surgical procedure. The majority of patients did not need any postoperative opioid (59% in the comfort group and 56% in the NRS group, P=0.2260). There was no difference in postoperative pain, nausea and vomiting, time to reach an Aldrete score ≥9 after extubation, and global satisfaction.

CONCLUSIONS

Using a comfort scale to assess pain in the PACU did not spare any opioid compared with use of a standard NRS. Further studies focusing on patients at risk of increased postoperative opioid consumption are necessary.

CLINICAL TRIAL REGISTRATION

NCT05234216.

Cross-cultural adaptation and psychometric validation of the French version of the Defense and Veterans Pain Rating Scale for acute and chronic pain: a prospective clinical study

BACKGROUND

Pain assessment and proper evaluation of pain are prerequisites for treatment of acute and chronic pain. Until now, most evaluations have used only resting pain intensity and a unidimensional scale, although multidimensional pain assessment and especially assessment of functional pain impact on activities are recommended. The Defense and Veterans Pain Rating Scale (DVPRS) permits this multidimensional assessment, but no validated French translation exists.

OBJECTIVES

To validate the French translation of the multidimensional DVPRS, called the Functional Pain Scale (FPS), in multiple settings of acute and chronic pain.

STUDY DESIGN

Prospective observational study.

SETTING

Two large hospitals in the French-speaking region of Switzerland.

METHODS

We recruited 232 patients from February 2022 to January 2023. Patients with acute or chronic pain in different settings received a paper questionnaire with both a numerical rating scale (NRS) and the FPS and a customized evaluation questionnaire. Correlation between the FPS and NRS, psychometric properties, and patient preferences were analyzed.

RESULTS

Correlation between the FPS and NRS was high for the whole group of 232 patients, as well for all subgroups. The multi-item FPS scale showed excellent internal consistency. A large majority of patients, even those >75 years of age, preferred the FPS over the NRS and stated that the FPS was easy to use.

CONCLUSIONS

The study confirms that the French translation of the DVPRS (the FPS) is a valid measurement instrument for acute and chronic pain evaluation in a wide range of patient groups and is easy for patients to use.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05307380.

Methodological quality of 100 recent systematic reviews of health-related outcome measurement instruments: an overview of reviews

PURPOSE

Systematic reviews evaluating and comparing the measurement properties of outcome measurement instruments (OMIs) play an important role in OMI selection. Earlier overviews of review quality (2007, 2014) evidenced substantial concerns with regards to alignment to scientific standards. This overview aimed to investigate whether the quality of recent systematic reviews of OMIs lives up to the current scientific standards.

METHODS

One hundred systematic reviews of OMIs published from June 1, 2021 onwards were randomly selected through a systematic literature search performed on March 17, 2022 in MEDLINE and EMBASE. The quality of systematic reviews was appraised by two independent reviewers. An updated data extraction form was informed by the earlier studies, and results were compared to these earlier studies' findings.

RESULTS

A quarter of the reviews had an unclear research question or aim, and in 22% of the reviews the search strategy did not match the aim. Half of the reviews had an incomprehensive search strategy, because relevant search terms were not included. In 63% of the reviews (compared to 41% in 2014 and 30% in 2007) a risk of bias assessment was conducted. In 73% of the reviews (some) measurement properties were evaluated (58% in 2014 and 55% in 2007). In 60% of the reviews the data were (partly) synthesized (42% in 2014 and 7% in 2007); evaluation of measurement properties and data syntheses was not conducted separately for subscales in the majority. Certainty assessments of the quality of the total body of evidence were conducted in only 33% of reviews (not assessed in 2014 and 2007). The majority (58%) did not make any recommendations on which OMI (not) to use.

CONCLUSION

Despite clear improvements in risk of bias assessments, measurement property evaluation and data synthesis, specifying the research question, conducting the search strategy and performing a certainty assessment remain poor. To ensure that systematic reviews of OMIs meet current scientific standards, more consistent conduct and reporting of systematic reviews of OMIs is needed.

Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis

BACKGROUND

Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia.

METHODS

We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points).

RESULTS

We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes.

CONCLUSIONS

Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023439896).

Implementing an Evidence-Based Functional Pain Assessment Scale in an Adult Inpatient Unit

BACKGROUND

The focus on pain assessment using a single, one-dimension pain assessment scale can be problematic. Locally, challenges we faced with this were; a) pain was percieved as not being effectively managed, b) patients with chronic pain were not having their pain adequately controlled, and c) misconceptions and subsequent confusion between health care teams and patients related to what pain intensity scores mean to each individual.

AIMS

The purpose of this paper is to describe an evidence-based practice project aiming at improving pain assessment through the implementation of a Functional Pain Scale (FPS) on an adult inpatient cardiothoracic unit.

DESIGN

The Iowa Model-Revised and the Implementation Strategies for Evidence- Based Practice Guide served as the framework for this project.

SETTING

Over an 18-month period at a academic tertiary medical center in the midwest.

PARTICIPANTS/SUBJECTS

Staff and patients on an adult inpatient 48-bed medical and surgical cardiothoracic unit.

METHODS

Following a synthesis of the evidence, implementation of the FPS required various strategies, such as, individualized patient and staff education, audit and feedback, a pain policy revision, and creating documentation in the electronic medical record. Evaluation of the FPS consisted of patient and staff surveys pre- and postimplementation to assess knowledge, attitudes, and behaviors.

RESULTS

After the pilot period, over 75% of the patients preferred to use the FPS and almost all the patients found the scale easy to use. Nurses reported an increase in perception that pain documentation was complete, that the FPS allowed them to accurately document their patients' pain experience, and that their patients were well informed of their pain management plan.

CONCLUSIONS

This project supports successful implementation of the FPS within nursing workflow. The goal of using the FPS is to change pain management discussions from an intensity reduction to meeting goals of care, aligning expectations, and creating common language among patients and providers.

Beyond measurement: a deep dive into the commonly used pain scales for postoperative pain assessment

This review explores the essential methodologies for effective postoperative pain management, focusing on the need for thorough pain assessment tools, as underscored in various existing guidelines. Herein, the strengths and weaknesses of commonly used pain scales for postoperative pain-the Visual Analog Scale, Numeric Rating Scale, Verbal Rating Scale, and Faces Pain Scale-are evaluated, highlighting the importance of selecting appropriate assessment tools based on factors influencing their effectiveness in surgical contexts. By emphasizing the need to comprehend the minimal clinically important difference (MCID) for these scales in evaluating new analgesic interventions and monitoring pain trajectories over time, this review advocates recognizing the limitations of common pain scales to improve pain assessment strategies, ultimately enhancing postoperative pain management. Finally, five recommendations for pain assessment in research on postoperative pain are provided: first, selecting an appropriate pain scale tailored to the patient group, considering the strengths and weaknesses of each scale; second, simultaneously assessing the intensity of postoperative pain at rest and during movement; third, conducting evaluations at specific time points and monitoring trends over time; fourth, extending the focus beyond the intensity of postoperative pain to include its impact on postoperative functional recovery; and lastly, interpreting the findings while considering the MCID, ensuring that it is clinically significant for the chosen pain scale. These recommendations broaden our understanding of postoperative pain and provide insights that contribute to more effective pain management strategies, thereby enhancing patient care outcomes.

Towards more tolerable subcutaneous administration: Review of contributing factors for improving combination product design

Subcutaneous (SC) injections can be associated with local pain and discomfort that is subjective and may affect treatment adherence and overall patient experience. With innovations increasingly focused on finding ways to deliver higher doses and volumes (≥2 mL), there is a need to better understand the multiple intertwined factors that influence pain upon SC injection. As a priority for the SC Drug Development & Delivery Consortium, this manuscript provides a comprehensive review of known attributes from published literature that contribute to pain/discomfort upon SC injection from three perspectives: (1) device and delivery factors that cause physical pain, (2) formulation factors that trigger pain responses, and (3) human factors impacting pain perception. Leveraging the Consortium's collective expertise, we provide an assessment of the comparative and interdependent factors likely to impact SC injection pain. In addition, we offer expert insights and future perspectives to fill identified gaps in knowledge to help advance the development of patient-centric and well tolerated high-dose/high-volume SC drug delivery solutions.

Enhanced Recovery After Surgery for Craniotomies: A Systematic Review and Meta-analysis

The efficacy of the enhanced recovery after surgery (ERAS) protocols in neurosurgery has not yet been established. We performed a systematic review and meta-analysis of randomized controlled trials to compare the effects of ERAS protocols and conventional perioperative care on postoperative outcomes in patients undergoing craniotomy. The primary outcome was postoperative length of hospital stay. Secondary outcomes included postoperative pain visual analog pain scores, incidence of postoperative nausea and vomiting (PONV), postoperative complications, all-cause reoperation, readmission after discharge, and mortality. A literature search up to August 10, 2023, was conducted using PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus databases. Five studies, including 871 patients, were identified for inclusion in this review. Compared with conventional perioperative care, ERAS protocols reduced the length of postoperative hospital stay (difference of medians, -1.52 days; 95% CI: -2.55 to -0.49); there was high heterogeneity across studies (I2, 74%). ERAS protocols were also associated with a lower risk of PONV (relative risk, 0.79; 95% CI: 0.69-0.90; I2, 99%) and postoperative pain with a visual analog scale score ≥4 at postoperative day 1 (relative risk, 0.37; 95% CI: 0.28-0.49; I2, 14%). Other outcomes, including postoperative complications, did not differ between ERAS and conventional care groups. ERAS protocols may be superior to conventional perioperative care in craniotomy patients in terms of lower length of hospital stay, lower incidence of PONV, and improved postoperative pain scores. Further randomized trials are required to identify the impact of ERAS protocols on the quality of recovery after craniotomy.

Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review

BACKGROUND

Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies.

METHODS

We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers.

RESULTS

Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number.

CONCLUSIONS

Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias.

STUDY REGISTRATION

OSF - https://osf.io/7kea3.

Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review

"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design.

Funding

None.

Comparing Apotel and Remifentanil for Multimodal Patient-Controlled Analgesia in Postoperative Pain Management Following Total Knee Arthroplasty Surgery: A Randomized Controlled Trial

Background

Total knee arthroplasty (TKA) is a standard surgical procedure for individuals with debilitating knee arthritis. Effective postoperative pain management is essential for successful recovery, although traditional opioid-based methods have limitations.

Objectives

This study aimed to compare the efficacy of Apotel and remifentanil patient-controlled analgesia in managing postoperative pain after TKA.

Methods

This double-blind, randomized, controlled clinical trial took place at Amir-al-Momenin and Qods Hospitals in Arak, Iran, spanning from June 2022 to September 2023. Sixty-two eligible patients scheduled for knee joint replacement were randomly assigned to receive either Apotel (Group A) or remifentanil (Group R) as part of multimodal analgesia administered via a pain pump for postoperative pain relief in TKA. The study assessed hemodynamic parameters, pain levels (measured using the Visual Analog Scale), analgesic duration, and narcotic consumption. Statistical analyses were performed using SPSS v.27 and Plotly.

Results

Subjects exhibited no statistically significant differences in age, gender distribution, duration of surgery, or anesthesia. The hemodynamic status assessment in the recovery room showed no significant differences in SPO2, PR, or MAP between the groups. However, remifentanil demonstrated superior effectiveness in reducing pain over 24 hours post TKA surgery compared to Apotel, as evidenced by lower average Visual Analog Scale (VAS) scores (P < 0.001), longer duration without the need for narcotic painkillers (P < 0.001), and lower cumulative opioid analgesic consumption in Group R (P < 0.001).

Conclusions

Remifentanil demonstrates superior pain control in a multimodal pain management approach compared to Apotel, providing sustained pain reduction over 24 hours post-surgery. Moreover, remifentanil offers longer-lasting pain relief and results in lower cumulative narcotic painkiller consumption compared to Apotel.

Consensus on the definition and criteria for failure of surgical treatment in bacterial arthritis of a native joint: An international Delphi study

PURPOSE

The literature presents a wide range of success rates for a single surgical intervention of bacterial-septic-arthritis, and there is a lack of clear criteria for identifying treatment failure and making decisions about reintervention. This Delphi study aims to establish a consensus among an international panel of experts regarding the definition of treatment failure and the criteria for reintervention in case of bacterial arthritis.

METHODS

The conducting and reporting Delphi studies (CREDES) criteria were used. Data from a systematic review was provided as the basis for the study. A list of 100 potential experts were identified. The study was designed and conducted as follows: (I) identification and invitation of an expert panel, (II) informing the participating expert panel on the research question and subject, and (III) conducting two or three Delphi rounds to reach consensus on explicit research items. Potential criteria were rated on a five-point Likert scale.

RESULTS

Sixty orthopaedic experts from nine countries participated in this Delphi study, with 55 completing all three rounds. The mean experience as an orthopaedic surgeon was 15 years (SD ± 9). Strong (96%) consensus was reached on the definition of treatment failure: the persistence of physical signs of arthritis (e.g., pain and swelling) and/or systemic inflammation (e.g., fever and no improvement in CRP) despite surgical and antibiotic treatment. Furthermore, consensus (>80%) was reached on six criteria influencing the decision for reintervention; pain (81%), sepsis (98%), fever (88%), serum CRP (93%), blood culture (82%), and synovial fluid culture (84%).

CONCLUSION

The definition of treatment failure for bacterial arthritis after a single surgical intervention was established through a three-round Delphi study. Additionally, consensus was reached on six criteria that are helpful for determining the need for reintervention. This definition and these criteria may help in the development of clinical guidelines, and will empower physicians to make more precise and consistent decisions regarding reintervention for patients, ultimately aiming to reduce over- and undertreatment and improve patient outcomes.

LEVEL OF EVIDENCE

Level V.

Corrugator Muscle Activity Associated with Pressure Pain in Adults with Neck/Shoulder Pain

Background and Objectives: No studies have reported corrugator muscle activity associated with pain in people with pain. This study aimed to develop an objective pain assessment method using corrugator muscle activity with pressure pain stimulation to the skeletal muscle. Methods: Participants were 20 adults (a mean ± SD age of 22.0 ± 3.1 years) with chronic neck/shoulder pain. Surface electromyography (sEMG) of corrugator muscle activity at rest (baseline) and without and with pressure pain stimulation applied to the most painful tender point in the shoulder was recorded. Participants evaluated the intensity of the neck/shoulder pain and the sensory and affective components of pain with pressure stimulation using a visual analogue scale (VAS). The percentages of integrated sEMG (% corrugator activity) without and with pressure pain stimulation to the baseline integrated sEMG were compared, and the relationships between the % corrugator activity and the sensory and affective components of pain VAS scores were evaluated. Results: Without pressure stimulation, an increase in corrugator muscle activity due to chronic neck/shoulder pain was not observed. The % corrugator activity with pressure pain stimulation was significantly higher than that without stimulation (p < 0.01). A significant positive correlation between corrugator muscle activity and the affective components of pain VAS scores with pressure stimulation was found (ρ = 0.465, p = 0.039) and a tendency of positive correlation was found for the sensory component of pain VAS scores (ρ = 0.423, p = 0.063). Conclusions: The increase in corrugator muscle activity with pressure pain stimulation to the tender point in adults with chronic neck/shoulder pain was observed, although increased corrugator muscle activity resulting from the chronic neck/shoulder pain was not. These findings suggest that corrugator muscle activity with pressure pain stimulation can be a useful objective indication for tender point sensitivity assessment in the skeletal muscle with pain.

Validation of general pain scores from multidomain assessment tools in stroke

Purpose

We describe how well general pain reported in multidomain assessment tools correlated with pain-specific assessment tools; associations between general pain, activities of daily living and independence after stroke.

Materials and methods

Analyses of individual participant data (IPD) from the Virtual International Stroke Trials Archive (VISTA) described correlation coefficients examining (i) direct comparisons of assessments from pain-specific and multidomain assessment tools that included pain, (ii) indirect comparisons of pain assessments with the Barthel Index (BI) and modified Rankin Scale (mRS), and (iii) whether pain identification could be enhanced by accounting for reported usual activities, self-care, mobility and anxiety/depression; factors associated with pain.

Results

European Quality of Life 3- and 5-Level (EQ-5D-3L and EQ-5D-5L), RAND 36 Item Health Survey 1.0 (SF-36) or the 0-10 Numeric Pain Rating Scale (NPRS) were available from 10/94 studies (IPD = 10,002). The 0-10 NPRS was the only available pain-specific assessment tool and was a reference for comparison with other tools. Pearson correlation coefficients between the 0-10 NPRS and (A) the EQ-5D-3L and (B) EQ5D-5 L were r = 0.572 (n = 436) and r = 0.305 (n = 1,134), respectively. mRS was better aligned with pain by EQ-5D-3L (n = 8,966; r = 0.340) than by SF-36 (n = 623; r = 0.318). BI aligned better with pain by SF-36 (n = 623; r = -0.320). Creating a composite score using the EQ-5D 3 L and 5 L comprising pain, mobility, usual-activities, self-care and anxiety/depression did not improve correlation with the 0-10 NPRS.

Discussion

The EQ-5D-3L pain domain aligned better than the EQ-5D-5L with the 0-10 NPRS and may inform general pain description where resources and assessment burden hinder use of additional, pain-specific assessments.

Measuring pain intensity through physical interaction in an experimental model of cold-induced pain: A method comparison study

OBJECTIVES

Assessment of pain is challenging given its subjective nature. Standard pain assessment tools have limitations. We aimed to compare the verbal numeric rating scale (NRS) and Grasp, a novel handheld electronic device that reports pain by squeezing.

METHODS

To compare Grasp and NRS, healthy adult volunteers were invited to undergo two subsequent standardised tests of cold-triggered pain using a cold pressor test (CPT) at a temperature of 3°C. Pain intensity was in a randomised manner reported by NRS (scale 0-10) or by squeezing Grasp (0-3 V) during the two CPTs. A third CPT was performed 1 to 14 days later where subjects reported pain by Grasp a second time in order to study the association of repeated Grasp measurements. Acceptable association was a priori considered as mean Kendall's τ-b coefficient (τ-b) ≥ 0.7. The subjects reported their experience of using Grasp in a purpose-made questionnaire.

RESULTS

In total, 102 subjects were included, and 96 subjects (56 females) completed all three tests. The association of pain intensity reported by Grasp and NRS was moderate with a mean τ-b of 0.53 (95% confidence interval [CI] 0.47-0.58). The association between the repeated Grasp measurements was weak with a mean τ-b of 0.43 (95% CI 0.37-0.48). Most subjects reported that Grasp was intuitive and easy to use.

CONCLUSIONS

Pain intensity reported by squeezing Grasp did not show acceptable association with pain intensity reported by NRS during CPTs. The association between pain intensity reported by Grasp during two CPTs on separate days was weak. Further improvements of the Grasp ball are needed before use in clinical settings.

Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Outcomes After Cardiothoracic Surgery

Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal-mediated anti-inflammatory reflexes. To investigate this relationship, we conducted a study with 55 patients undergoing minimally invasive cardiothoracic surgery to evaluate whether cardiovagal baroreflex sensitivity (BRS) can predict postoperative pain. We assessed the spontaneous cardiovagal BRS under resting pain-free conditions before surgery. We estimated postoperative pain outcomes with the Pain, Enjoyment, and General Activity scale and pressure pain thresholds on the first (POD1) and second (POD2) postoperative days and persistent pain 3 and 6 months after hospital discharge. We also measured circulating levels of relevant inflammatory biomarkers (C-reactive protein, albumin, cytokines) at baseline, POD1, and POD2 to assess the contribution of inflammation to the relationship between BRS and postoperative pain. Our mixed-effects model analysis showed a significant main effect of preoperative BRS on postoperative pain (P = .013). Linear regression analysis revealed a significant positive association between preoperative BRS and postoperative pain on POD2, even after adjusting for demographic, surgical, analgesic treatment, and psychological factors. Moreover, preoperative BRS was linked to pain interfering with general activity and enjoyment but not with other pain parameters (pain intensity and pressure pain thresholds). Preoperative BRS had modest associations with postoperative C-reactive protein and IL-10 levels, but they did not mediate its relationship with postoperative pain. These findings indicate that preoperative BRS can independently predict postoperative pain, which could serve as a modifiable criterion for optimizing postoperative pain management. PERSPECTIVE: This article shows that preoperative BRS predicts postoperative pain outcomes independently of the inflammatory response and pain sensitivity to noxious pressure stimulation. These results provide valuable insights into the role of baroreceptors in pain and suggest a helpful tool for improving postoperative pain management.

Management of Acute Sickle Cell Disease Pain

Pain is a common complication of sickle cell disease. Sickle cell pain can often be effectively managed by pediatricians in outpatient and hospital settings. Acute pain management should be initiated quickly. Patients need to be evaluated for sickle cell complications and other causes of pain. Nonsteroidal anti-inflammatory drugs and opioids are the mainstay of pain treatment, but additional therapies include hydration, local pain control, muscle relaxants, and nonpharmacologic approaches. Healthy lifestyle habits and good behavioral and mental health are important for preventing and coping with sickle cell disease pain. Disease-modifying therapies, such as hydroxyurea, can help prevent sickle hemoglobin polymerization and acute pain episodes. Because sickle cell disease largely affects people who are racialized minorities in the United States, health-care providers need to be aware of how their own personal biases may affect care of these patients.

Correlation between Harris hip score and gait analysis through artificial intelligence pose estimation in patients after total hip arthroplasty

BACKGROUND

Recently, open pose estimation using artificial intelligence (AI) has enabled the analysis of time series of human movements through digital video inputs. Analyzing a person's actual movement as a digitized image would give objectivity in evaluating a person's physical function. In the present study, we investigated the relationship of AI camera-based open pose estimation with Harris Hip Score (HHS) developed for patient-reported outcome (PRO) of hip joint function.

METHOD

HHS evaluation and pose estimation using AI camera were performed for a total of 56 patients after total hip arthroplasty in Gyeongsang National University Hospital. Joint angles and gait parameters were analyzed by extracting joint points from time-series data of the patient's movements. A total of 65 parameters were from raw data of the lower extremity. Principal component analysis (PCA) was used to find main parameters. K-means cluster, X-squared test, Random forest, and mean decrease Gini (MDG) graph were also applied.

RESULTS

The train model showed 75% prediction accuracy and the test model showed 81.8% reality prediction accuracy in Random forest. "Anklerang_max", "kneeankle_diff", and "anklerang_rl" showed the top 3 Gini importance score in the Mean Decrease Gini (MDG) graph.

CONCLUSION

The present study shows that pose estimation data using AI camera is related to HHS by presenting associated gait parameters. In addition, our results suggest that ankle angle associated parameters could be key factors of gait analysis in patients who undergo total hip arthroplasty.

Healthcare delivery gaps in pain management within the first 3 months after discharge from inpatient noncardiac surgeries: a scoping review

BACKGROUND

Poor pain control during the postoperative period has negative implications for recovery, and is a critical risk factor for development of persistent postsurgical pain. The aim of this scoping review is to identify gaps in healthcare delivery that patients undergoing inpatient noncardiac surgeries experience in pain management while recovering at home.

METHODS

Searches were conducted by a medical librarian in PubMed, MEDLINE, EMBASE, EBSCO CINAHL, Web of Science, and Cochrane Database of Systematic Reviews for articles published between 2016 and 2022. Inclusion criteria were adults (≥18 yr), English language, inpatient noncardiac surgery, and included at least one gap in care for acute and/or persistent pain management after surgery within the first 3 months of recovery at home. Two reviewers independently screened articles for inclusion and extracted data. Quotations from each article related to gaps in care were synthesised using thematic analysis.

RESULTS

There were 4794 results from databases and grey literature, of which 38 articles met inclusion criteria. From these, 23 gaps were extracted, encompassing all six domains of healthcare delivery (capacity, organisational structure, finances, patients, care processes and infrastructure, and culture). Identified gaps were synthesised into five overarching themes: education (22 studies), provision of continuity of care (21 studies), individualised management (10 studies), support for specific populations (11 studies), and research and knowledge translation (10 studies).

CONCLUSIONS

This scoping review identified health delivery gaps during a critical period in postoperative pain management. These gaps represent potential targets for quality improvement and future research to improve perioperative care and longer-term patient-centred outcomes.

SCOPING REVIEW PROTOCOL

Open Science Framework (https://osf.io/cq5m6/).

Validation of an instrument for dentists' perception of pain in patients with communication difficulties

Pain is present in the dental clinic, whether due to oral problems such as dental caries and its complications or related to dental procedures. Pain evaluation in patients with communication difficulties (PCDs) is challenging for dentists, potentially compromising treatment. The aim of this study was to develop and validate an instrument to assess the perception of dentists about pain in PCDs. This study followed a quantitative methodological approach involving constructing and validating an instrument administered to 50 dentists. The initial instrument consisted of 29 items divided into four domains. Content and construct validity and internal consistency were confirmed. Content validation was performed by judges using the Content Validity Index. The instrument underwent construct validation and internal consistency assessments through exploratory factor analysis and confirmatory factor analysis using Cronbach's α, Kaiser-Meyer-Olkin, and Bartlett's sphericity tests. The final instrument consisted of 21 items divided into three domains, with a high Cronbach's α for one domain and moderate values for the others. The total variance accounted for was above 46.03%. Each factor retained at least three items, with factor loadings greater than 0.3, commonalities greater than 0.2, and eigenvalues >1. Despite the study's limitations, the instrument demonstrated its applicability and potential in evaluating the perception and management of pain in PCDs.

Opioid prescribing for acute postoperative pain: an overview of systematic reviews related to two consensus statements relevant at patient, prescriber, system and public health levels

BACKGROUND

National guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm.

OBJECTIVES

This overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 recommendations from two previously published consensus guideline papers (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain.

METHODS

A systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed.

RESULTS

A total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality.

CONCLUSION

The consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue.

The mechanisms and management of persistent postsurgical pain

An estimated 10%-50% of patients undergoing a surgical intervention will develop persistent postsurgical pain (PPP) lasting more than 3 months despite adequate acute pain management and the availability of minimally invasive procedures. The link between early and late pain outcomes for surgical procedures remains unclear-some patients improve while others develop persistent pain. The elective nature of a surgical procedure offers a unique opportunity for prophylactic or early intervention to prevent the development of PPP and improve our understanding of its associated risk factors, such as pre-operative anxiety and the duration of severe acute postoperative pain. Current perioperative pain management strategies often include opioids, but long-term consumption can lead to tolerance, addiction, opioid-induced hyperalgesia, and death. Pre-clinical models provide the opportunity to dissect mechanisms underpinning the transition from acute to chronic, or persistent, postsurgical pain. This review highlights putative mechanisms of PPP, including sensitisation of peripheral sensory neurons, neuroplasticity in the central nervous system and nociceptive signalling along the neuro-immune axis.

Early Feasibility of an Activity-Based Intervention for Improving Ingestive Functions in Older Adults with Oropharyngeal Dysphagia

There is growing awareness about the use of combined strength- and skill-based swallowing training for improving swallowing physiology in the event of dysphagia. Such an approach involves focusing on coordination and timing as well as swallowing strengthening in the context of increased exercise complexity in eating and drinking activities. This study aimed to determine the early feasibility of a newly developed 12-week intervention, named the ACT-ING program (ACTivity-based strength and skill training of swallowing to improve INGestion), in older adults with dysphagia and generalized sarcopenia. In a multiple-case-study design, seven participants above 65 years of age (five women and two men) with slight to severe dysphagia and indications of sarcopenia underwent the intervention during hospitalization and in the community after discharge. The ACT-ING program met most of the feasibility marks in terms of demand (73.3% of those invited accepted participation), safety (100%), no reports of adverse events, tolerance (85.7%), usability (100%), and acceptability (100%). Three putative mediators of change (experienced autonomy support, in-therapy engagement, and perceived improvement in swallowing capacity) appeared to have been best accomplished in participants with slight to moderate dysphagia. The ACT-ING program showed preliminary evidence of early feasibility, warranting further early-phase dose articulation and proof-of-concept trials.

The effect of a quality improvement project on post-operative opioid use following outpatient spinal surgery

BACKGROUND

Prescribing opioids upon discharge after surgery is common practice; however, there are many inherent risks including dependency, diversion, and medical complications. Our prospective pre- and post-intervention study investigates the effect of a standardized analgesic prescription on the quantity of opioids prescribed and patients' level of pain and satisfaction with pain control in the early post-operative period.

METHODS

With the implementation of an electronic medical record, a standardized prescription was built employing multimodal analgesia and a stepwise approach to analgesics based on level of pain. Patients received an education handout pre-operatively explaining the prescription. Consecutive patients over a three-month period undergoing elective spine surgery as day or overnight stay cases who received usual care were compared to a similar cohort who received the standardized prescription and education. Patient satisfaction with post-operative pain control, post-operative pain scores, number of refills required, and opioids prescribed in oral morphine equivalents (OMEs) were compared before and after implementation of the standardized analgesic prescription.

RESULTS

Twenty-six patients received usual care (Control group) and 26 patients received the standardized prescription and education handout (Intervention group). There were significantly fewer OMEs prescribed in the Intervention group compared to the Control group. There was no difference between groups in: patient post-operative pain intensity score, post-operative satisfaction score, or number of refills required.

CONCLUSIONS

This study demonstrates that a standardized prescription consisting of an appropriate amount of opioid and non-opioid analgesics is effective in reducing the OMEs prescribed post-operatively in elective spine surgery procedures, without compromising patient pain control or satisfaction or increasing the number of refills required.

Use of Scheduled Nonopioid Analgesia to Decrease Inpatient Opioid Consumption After Scheduled Cesarean Birth

OBJECTIVE

To compare opioid use and pain scores in women who had scheduled cesarean birth before and after implementing a scheduled nonopioid analgesia practice guideline.

DESIGN

Quality improvement project with a comparison of pre-/postintervention.

SETTING/LOCAL PROBLEM

A 170-bed community hospital where the administration of postcesarean pain medications was unstandardized.

PARTICIPANTS

Convenience sample of 175 individuals who were scheduled for cesarean birth (106 in preintervention group and 69 in postimplementation group).

INTERVENTION/MEASUREMENTS

All participants had received a dose of 150 mcg of intrathecal morphine intraoperatively. Care of participants in the postimplementation group included a new practice guideline using preoperative oral acetaminophen 1 g and postoperative intravenous ketorolac 30 mg that transitioned to ibuprofen 600 mg orally every 6 hours until discharge. Acetaminophen 1 g every 6 hours also continued until discharge. For breakthrough pain, oxycodone 5 mg to 10 mg was available.

RESULTS

Results were analyzed using the chi-square and t test. There was a statistical difference in the mean milligram morphine equivalent consumed after scheduled cesarean birth (preintervention = 21.15 vs. postintervention = 3.91, p < .001). Postimplementation, 84.1% of participants did not consume any opioids beyond the intrathecal dose compared to 47.2% of participants preintervention. Mean pain scores decreased from 2.49 to 1.62 (p < .001), and there was an observed decrease of the highest reported pain score from 5.39 to 4.03 (p < .001).

CONCLUSION

The results of this project support the current literature indicating that the administration of a scheduled nonopioid multimodal analgesia regimen to individuals with scheduled cesarean birth is an effective postoperative pain management strategy. This approach to managing surgical birth pain can decrease subjective reports of pain and overall opioid consumption during the hospital stay.

Intracapsular tonsillectomy in the treatment of recurrent and chronic tonsillitis in adults: a protocol of a prospective, single-blinded, randomised study with a 5-year follow-up (the FINITE trial)

INTRODUCTION

The standard surgical treatment for recurrent or chronic tonsillitis is extracapsular tonsillectomy. Recent studies show that intracapsular tonsillectomy has the potential to reduce the postoperative morbidity of patients undergoing tonsil surgery. The Finnish Intracapsular Tonsillectomy (FINITE) trial aims to provide level I evidence to support the hypothesis that the recovery time from tonsil surgery can be reduced with intracapsular tonsillectomy. Additionally, from this trial, major benefits in quality of life, reduction of postoperative complications, treatment costs and throat symptoms might be gained.

METHODS AND ANALYSIS

The FINITE trial is a prospective, randomised, controlled, patient-blinded, three-arm clinical trial. It is designed to compare three different surgical methods being extracapsular monopolar tonsillectomy versus intracapsular microdebrider tonsillectomy versus intracapsular coblation tonsillectomy in the treatment of adult patients (16-65 years) suffering from recurrent or chronic tonsillitis. The study started in September 2019, and patients will be enrolled until a maximum of 200 patients are randomised. Currently, we are in the middle of the study with 125 patients enrolled as of 28 February 2022 and data collection is scheduled to be completed totally by December 2027. The primary endpoint of the study will be the recovery time from surgery. Secondary endpoints will be the postoperative pain scores and the use of analgesics during the first 3 weeks of recovery, postoperative haemorrhage, quality of life, tonsillar remnants, need for revision surgery, throat symptoms, treatment costs and sick leave. A follow-up by a questionnaire at 1-21 days and at 1, 6, 24 and 60 months will be conducted with a follow-up visit at the 6-month time point.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Medical Ethics Committee of the Hospital District of Southwest Finland (reference number 29/1801/2019). Results will be made publicly available in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03654742.

No place for routine use of modified-release opioids in postoperative pain management

Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.